Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses

Background Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people’s access or intention to healthcare systems. Objective To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic. Methods Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel. Result There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients. Conclusions COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat. Supplementary Information The online version contains supplementary material available at 10.1186/s12992-022-00836-2.


Introduction
Coronavirus disease 2019 , the highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1] was first reported on December 31, 2019, in Wuhan, China. One month later, on January 30, 2020, it was declared a global health emergency [2] compelling the World Health Organization (WHO) to declare it as a global pandemic on March 11, 2020. Globally, more than 6 million deaths are reported worldwide across 222 countries [3]. The virus affects the respiratory system and produces mild to severe respiratory illness, and might contribute to hospitalization, mechanical ventilation in intensive care units, and even death in some cases [4]. The severity of illness might get increased in people of older age, immunocompromised individuals, and those having premedical co-morbidities such as diabetes, cardiovascular disease, respiratory disease, and cancers [4,5]. Since the world health organization declared COVID-19 a global pandemic, COVID-19 was not just a health threat but its prolonged national lockdowns and modified lifestyle of people have affected various aspects of almost every sector's life. For example, it reduced students' access to education, increased food insecurity to millions of people, increased poverty, worsened mental health of both the healthcare professionals and the general population, and increased the burden on healthcare services [3,6].
Healthcare services utilization at the inpatient, outpatient, and emergency departments settings dropped due to the restrictive measures [7,8]. Moreover, plenty of literature reported a reduction in the emergency department (ED) visits during the pandemic period [9,10]. Diagnostic delays caused by the COVID-19 are mentioned to cause a major rise in the incidence of preventable cancer deaths in England [11]. Another report has approximated that 41% of individuals in the United States have postponed or avoided medical care, including urgent (12%) or non-urgent care (32%) [12]. Emergency medical care or urgent care, being provided by ED for individuals who arrive at the hospital, is defined as "Acute illness or damage that threatens life or function and needs prompt medical intervention. The patient would get hurt if there would be a delay" [13]. ED is responsible for stabilizing patients with life-threatening conditions and arrangement of admission of patients to special care facilities [13]. Healthcare avoidance is a type of patient disengagement that leads them to delay seeking medical care [14]. In some circumstances in the COVID-19 era, people experiencing urgent medical emergencies had been avoiding healthcare services due to the fear of contagion. Additionally, the EDs have also seemed to give lesser priority to non-COVID-19 patients comparatively [15]; while emergency medical health services are equally important irrespective of suffering from COVID or not. This reduction in the overall healthcare services utilization might worsen health outcomes for patients with other chronic diseases or acute medical emergencies [16]. Some studies also reported delayed emergency medical care in the case of pre-hospital services like the response to out-of-hospital cardiac arrest [17]. Others showed that the untimely and improper management of emergency medical needs increased morbidity and mortality of non-COVID-19 patients during the pandemic [11,12,15,16]. These dysfunctions in healthcare management may delay the achievement of the Sustainable Development Goals (SDG) published by the United Nations. Indicators of sustainable development seek to ensure long-term stability in the economy, health, education, and the environment [18]; while it seems that COVID- 19 have been imposing burdens of health financing on other aspects of SDG and even influencing significant portions of the healthcare system itself, in non-COVID-19 diseases care. As recently many studies have paid attention to the impacts of the pandemic on non-COVID-19 diseases management, reviewing these studies is needed for developing policies for shaping the normal postpandemic healthcare system. As a response, we should immediately identify factors linked to healthcare delays, especially in urgent care, that are related to higher mortality and morbidity rates. These factors might be related to the healthcare system as well as pre-hospital services or long wait times in the emergency department or might be due to patient-related factors as well as avoidance of care due to fear of COVID-19. Therefore, the aim of this study is to evaluate the impact of the COVID-19 pandemic on medical emergencies and time-sensitive emergency health conditions that require urgent care within a specified time to avoid mortality and morbidity. This study will help to understand, identify and document the impacts of the global COVID-19 pandemic on the emergency healthcare services, and provide valuable evidence to improve policy and management of emergency medical care in the context of a global pandemic.
condition. The PICO (Population, Intervention, Comparison, and Outcomes) conceptualized for this study is shown in Table 1. The population of interest is healthy/ stable patients being visited in ED for an emergency condition. The ED is responsible for stabilizing patients' vital signs and providing the necessary medical consultations for patients to enter special wards or operating rooms. Particularly, ED physicians make consultations with specialties in General Medicine (Neurology, Cardiology, Nephrology, Gastrointestinal, Endocrinology, Rheumatology), General Surgery, Pediatrics, Obstetrics, gynecology, and Urology. We considered these classifications to comprehensively include all possible emergency conditions. We limited the analysis to conditions with a specific golden time/hour or any outcome showing the incidence of delayed care (for example orchiectomy is preventable for testicular torsion if being treated at golden hours). The phrase "golden hour" was invented to emphasize the importance of timely emergency care in a time window that treatment would most prevent mortality and morbidity [28]. Outcomes of interest were the prevalence of failure/disruption of treatment due to delayed referral and onset to hospital door time, and onset to treatment time. We compared two time periods, before and during COVID-19. Based on this concept, and using the National Confidential Enquiry into Patient Outcome and Death (NCE-POD) classification of intervention [29], diseases that need interventions that a reservation is being made before a routine hospitalization (elective intervention) and diseases that do not pose a threat to life, limb, or organ survival within a few days after deciding to conduct the intervention (expedited intervention) were not included in our study scope; whereas diseases that needed intervention immediately or within hours of the decision to operate were included in our study. But inhospital timings like patient waiting time and delayed decision makings were waived in this study as our primary literature review did not show the feasibility of meta-analysis due to low data availability.
So, our study question was conceptualized to be "has the incidence of [endpoint marking delayed healthcare seeking] in [a medical emergency] been changed in comparison of patients referring to EDs before and during the COVID-19?" or "has the time of disease symptom onset to ED room been changed in comparison of patients referring to EDs before and during the COVID-19?" This Systematic review study was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Selected populations of interest (the emergency condition) attributed MeSH terms were considered as main keywords. Search strings used for the selected conditions are listed in supplementary Table 1. In each panel, 2 independent researchers performed the literature review.
The inclusion criteria for studies in this study were english articles that had reported variables of interest before and during the COVID-19 pandemic in the same medical centers. After removing the duplicated search results, potentially relevant studies were collected for eligibility assessment. A third researcher judged the study in which the last two independent researchers didn't agree to include. The search process is summarized in Fig. 1. Reference lists of studies were also hand queried for relevant references.

Data extraction
In the case of the ACS panel, patient-related delay indicators were chosen to be the median time of symptom onset to first medical contact and symptom onset to administration in all ACS cases (STEMI and NSTEMI), and rate of delayed administration in STEMI cases (> 12 h). In acute appendicitis panel, perforated appendicitis rate, diagnosed in operation and later than 72 hours ED visit were considered as outcomes. In aneurismal SAH, vasospasm findings on CT angiography and The World Federation of Neurological Surgeons (WFNS) score higher than 3 and Fisher grade of higher than 2 (which is showing the amount of hemorrhage) were considered. Tissue plasminogen activator (rt-PA) administration rate and symptoms onset to ED door time was considered for stroke. Rupture of ectopic pregnancy, orchiectomy, and DKA presentation was chosen as indicators of delayed presentation in ectopic pregnancy, testicular torsion, and newly diagnosed T1DM panels, respectively. Study id, time frames, and country were also extracted.

Analysis
Data of Studies with Quantitative outcomes of interest (time from onset to hospital or treatment) were collected and analyzed with Difference in Means or Difference of medians (DoM) in r packages. Data of studies with binary outcomes of interest (treatment failure or event of delayed care sought) were extracted in form of event rate in the total number of cases, before and during the COVID-19 pandemic. Binary data of rates were extracted as proportions of total study sample risk ratio was calculated to be pooled.
The Cochran Q test (two-test for heterogeneity) was used to assess the heterogeneity of the studies. I 2 was used to calculate the percentage of total heterogeneity to total variability. A Q test with a P < 0.1 or an I 2 statistic of greater than 60% was considered significant statistical heterogeneity. The random-effects model or fixed-effect model was used in case of heterogeneity presence or not, respectively. A 2-sided P < 0.05 was considered statistically significant. Publication Bias assessment was conducted by Funnel plot to depict publication bias. Egger's bias test was used to determine asymmetry.
Relative change in disease incidence was visualized on a world map created using Datawrapper online tool (https:// app. dataw rapper. de) and it is based on data provided by studies reporting parallel timeframe of the prepandemic and pandemic period.

Results
Following the literature review, 96 studies were included in the study in 7 panels for different medical conditions of (i) DKA Table 2. A total number of 139,542 patients were included in the before COVID-19 cohort and 84,601 in the COVID-19 cohort.

Highlights of the results
We found significant changes in the pattern of patients' referral to EDs in the case of ACS, aneurismal SAH, acute appendicitis, newly diagnosed T1DM, and testicular torsion with the emergence of the pandemic; while other medical emergencies did not show significant differences. Here the details of statistical analyses for pooling the studies are presented separately for each panel.
As shown in Table 2, 28 studies were eligible in the stroke panel; of which 21 studies were included in the time metrics meta-analysis of Differences of Medians (DoM) of symptoms onset to ED door, and 25 were included in the meta-analysis of the proportion of rt-PA administration. Based on the random-effects model, there were no significant differences in median time from symptoms onset to ED door between pre-and during-COVID-19 cohorts in CVA subjects (DoM = 15.67 min, 95% CI:-22.84 to 54.18 min; P = 0.425, supplementary Fig. 1). However, we found high heterogeneity between studies (I 2 = 98.31%) with no evidence of publication bias (Funnel Plot Asymmetry P = 0.969, supplementary Fig. 2). We did not recognize any source to evaluate as a meta-regression model to explain the high amount of heterogenicity.
In the case of the proportion of rt-PA administration among all CVA patients, based on the randomeffects model, with a high value of heterogenicity and Cross-Sectional Studies) was used to assess the quality of included studies and ranking studies in three categories of "good", "fair", and "poor". (https:// www. nhlbi. nih. gov/ health-topics/ study-quali ty-asses sment-tools)   Fig. 3). We did not observe evidence of publication bias (P = 0.541, supplementary Fig. 4). Nine studies had reported ACS symptom onset to first medical contact of which 3 studies had subgroups in different time frames that finally 12 study/sub-group data was entered meta-analysis. Meta-analysis using a random-effects model (I 2 = 99.52%) revealed no significant difference in DoM of symptom onset to first medical contact (minutes) in comparison of pre-COVID-19 cohorts with COVID-19 cohorts (DoM = 65.71 min, 95% CI:-11.55 to 142.98; P = 0.0955); while there was a high possibility of publication bias or small study effects due to asymmetry of the funnel plot (P = 0.0281), supplementary Fig. 5. The trim-filling method was not successful in eliminating bias and after using the trimfill method publication bias was still present; more advanced statistical methods are needed in the case of DoM.
Seven studies had reported symptom onset to first medical contact of which 1 study had subgroups in different time frames that finally 8 study/sub-group data was entered meta-analysis. Meta-analysis with random-effects model (I 2 = 61.21%; Q(df = 7) = 18.91, P = 0.0085) revealed significant increase in DoM of symptom onset to administration (minutes) in comparison of pre-COVID-19 cohorts with COVID-19 cohorts (DoM = 30.94 min, 95% CI:12.919 to 48.966; P = 0.0008); with no evidence for publication bias or small study effects (P = 0.0892).
In neurosurgery panel, aneurismal subarachnoid hemorrhage was chosen as emergency condition in which delayed health care sought was considered as vasospasm finding on CT angiography, Fisher grade > 2, and WFNS > 3. There were only 2 eligible studies. Due to I 2 = 0.0% (Q(df = 1) = 0.0153, P = 0.901), we preferred to perform the meta-analysis. In a fixed effect model, there was a powerful statistically significant increased rate of vasospasm finding on CT angiography in comparison of Pre-COVID-19 and COVID-19 cohort (RR = 1.575, 95% CI:0.72 to 2.42; P = 0.003), as shown in supplementary In the urology panel, in the case of testicular torsion, 6 studies were selected to be included in the meta-analysis of orchiectomy rate among testicular torsion cases, being age limited to pediatric cases to decrease the heterogeneity. In a fixed-effects model, with heterogeneity of 3%, RR was estimated to be 0.259 (95% CI:0.026 to 0.492; P = 0.029, supplementary Fig. 9) and no publication bias evidence (regression test for funnel plot asymmetry p = 0.883, supplementary Fig. 9). This was indicating a statistically significant rise in the rate of orchiectomy rate among testicular torsion in COVID-19 cohorts compared to pre-COVID-19.
In Endocrinology/pediatrics panel, in the case of newly diagnosed type 1 diabetes mellitus (T1DM), 8 studies were included in the meta-analysis of DKA presentation rate among T1DM cases, being age limited to pediatric cases to decrease the heterogeneity. Using a random-effects model, RR was estimated to be 0.224 (95% CI:0.062 to 0.38; p = 0.0065) and no publication bias evidence (regression test for funnel plot asymmetry P = 0.915, supplementary Fig. 10). The results presented in individual studies were moderately heterogeneous (I 2 = 49.37%, Q(df = 7) = 14.98, P = 0.0362, supplementary Fig. 11). This shows a statistically significant increase in the rate of DKA presentation rate among T1DM patients, comparing pre-COVID-19 and COVID-19 cohorts.
In Obstetrics and gynecology panel, in the case of ectopic pregnancy, 8 studies were selected to be included in the meta-analysis of rupture of ectopic pregnancy rate among all ectopic pregnancy cases. In a random-effects model, with heterogeneity of 56.20% (Q(df = 7) = 17.0353, P = 0.0172, supplementary Fig. 12), RR was estimated to be 0.112 (95% CI:0.0248 to 0.201; p = 0.0065); but there was potential possibility of publication bias (regression test for funnel plot asymmetry P = 0.0121, supplementary Fig. 13). So, using the trim and fill method, 4 studies were filled, and the final RR was 0.0670 (CI95%: − 0.0064 to 0.1404; p = 0.0734, supplementary Figs. 14 and 15). So, there were no significant changes in the rate of EP rupture before and during the pandemic.
In the general surgery panel, in the case of acute appendicitis, 20 studies were selected to be included in the meta-analysis of Perforated appendicitis rate among all acute appendicitis cases, diagnosed based on post-operation findings. To minimize possible heterogeneity, adultaged studies were included. In a Fixed-Effects Model, with heterogeneity of 18.59%, RR was estimated to be 0.362(CI95%:0.2549 to 0.4690; p < .0001; supplementary Fig. 16) and no publication bias evidence (regression test for funnel plot asymmetry p-value = 0.242; supplementary Fig. 17). This shows a statistically significant increase in the rate of the perforation rate among acute appendicitis patients, comparing pre-COVID-19 and COVID-19 cohorts. of 20 selected articles, 3 studies reported late symptom onset to ED referral rate in case of later than 72 hours ED visit to symptom onset time. In a metaanalysis of later than 72 h referral, using a random-effects model, with a heterogeneity of 75.32%, RR was estimated to be 0.641(CI95%: − 0.6104 to 1.8938; p = 0.315, supplementary Figs. 18 and 19). There were no significant changes in the rate of late referral (Table 3).
Studies in which the time frames of pre-COVID-19 and COVID-19 cohorts were the same months of years were selected for estimation of the relative change of incidence. Based on the provided data which is shown in Table 2, the worldwide relative change of incidence was visualized in Fig. 2.

Discussion
The sharp drop in emergency department admissions is mentioned in various studies ; however, according to our knowledge, no previous study has provided  systematic evidence to support this view worldwide. We found that when comparing the pre-COVID-19 and COVID-19 cohorts of CVA patients, there were no substantial differences in the occurrence rate of obtaining rt-PA or the median time from symptom start to hospital room. In the case of ACS, the duration from symptom start to administration was significantly longer in pre-COVID-19 cohorts than in COVID-19 cohorts. When comparing the Pre-COVID-19 and COVID-19 cohorts of patients with aneurismal subarachnoid hemorrhage, there was a statistically significant higher prevalence of vasospasm on CT angiography; nevertheless, vasospasm indicates a delayed referral to hospital. In comparison to the pre-COVID-19 and COVID-19 cohorts, there was a statistically significant increase in the risk of perforation among acute appendicitis patients. There were no significant differences in the rate of ruptured Ectopic Pregnancy before and after the epidemic. When comparing the pre-COVID-19 and COVID-19 cohorts, there was a substantial rise in the rate of DKA presentation among T1DM patients as well as perforation rate among ectopic pregnancy patients. Similar to our study, Ojetti et al. attributed decreased admission of cardio-thoracic, gastroenterological, urological, otolaryngologic/ophthalmologic, and traumatological during the pandemic to fear of the virus, implying that patients with serious diseases did not seek treatment in the emergency department [122]. Toniolo et al. found that severe emergent cardiovascular diseases admissions were decreased during the pandemic in Italy [123]; a pooled analysis of similar studies showed a significant reduction in admission in a large comparison of 50,123 patients [124]. Several other studies are showing similar findings in many other medical conditions as well as surgical complaints [125], urological emergencies [126], and most other emergency department visits [127,128]. All these studies unanimously warn of the danger of not paying attention to emergencies; while the decreased admission records could have happened due to various reasons. The changed use of the emergency department for the management of COVID-19 cases might be a reason that raises concerns about the disparities in healthcare. Previously, the concept of health disparities referred more to social differences and was addressing ethnicity and cultural minorities in the society, but COVID-19 era studies and the results of our study reveal a new concept of health disparities. Health disparities are one of the most important issues related to health policy and economics and are a major problem in the field of public health and social inequality. Health disparities are a general term used to denote the differences, variations, and disparities in access to health of individuals or groups [129]. While some researches show that elderly [130], Black populations, rural communities, and incarcerated populations [129] might experience inequality in healthcare; our previous study about Afghan refugees in Iran as a minor ethnicity [131] show that the need for active patient identification and treatment has lead widespread diagnostic and therapeutic measures of COVID-19 for patients with any social, economic, and cultural backgrounds and now we are facing a different side of the health disparity. Because the world's healthcare market has been shifted to COVID-19 healthcare, governmental interventions are required to cover services for all people with other diseases, therefore, the study of inequality can provide accurate and reliable information on how health services are distributed to health planners and policymakers can determine the population groups that use the emergency services the least. In this study, we found some critical medical conditions that seem that the population affected by these diseases is receiving the required services lately; while statistics of mentioned studies might be showing patient-related decreased visits. In this study, we focused on patientrelated delayed care-seeking. For this aim, known indicators of delayed healthcare sought were used to assess the hypothesis. Management of some emergency conditions is very time-critical and the best time to treat these diseases is called the Golden time or golden hour. We tried to address these medical conditions by pooling time metrics of patients' referrals to emergency centers or in some cases, the final disease outcome that was showing delayed medical care were also compared before and during the pandemic. CVA and ACS were assessed mainly by time metrics. We found 25 studies that reported data of 7124 subjects experiencing CVA during the pandemic with more than seventy thousand subjects before the pandemic, time metrics of patient referral, and outcome of the rt-PA administration in proper time has not significantly changed; while as Fig. 2 shows ecological disparities exist. But, in the ACS panel, there was an increased symptom onset to administration time (30.94 min, 95% CI:12.919 to 48.966). We were aware of the possibility of the effect of the pre-hospital emergency care service delays and we also evaluated time to first medical contact that our analyses of time to first medical contact became worthless due to the possibility of bias and we were not able to address this by analytical methods.
Aneurysmal subarachnoid hemorrhage is a life-threatening condition that needs immediate medical attention. Delayed cerebral ischemia is a common issue that can lead to poor neurological results. The major cause of delayed cerebral ischemia is assumed to be cerebral vasospasm [132,133]. We found that the presentation of SAH cases with vasospasm finding on CT angiography in comparison of Pre-COVID-19 and COVID-19 cohorts has shown a significantly higher incidence of vasospasm during the pandemic (OR = 1.575); while the number of studies included in the meta-analysis is low.
Our study revealed that DKA presentation in newly diagnosed T1DM patients has tended to get increase following the COVID-19 pandemic. It highlights the need for appropriate organization of healthcare resources, particularly for pediatric situations [134].
Due to parents' concerns about the COVID-19 pandemic, visits to medical centers during the quarantine period may have occurred later than the pre-quarantine period [135]. Caregivers may mistakenly attribute symptoms to COVID-19 rather than DKA, resulting in an elevated severity of illness at the time of presentation with acute symptom start. Consequently, besides the organization of healthcare resources, the healthcare system has to educate patients and their families about life-threatening conditions and encourage them to look for help when needed.
Individuals will continue to experience fast metabolic decompensation, resulting in DKA, if the diagnosis of DM1 is delayed [136], as we saw during the COVID-19 pandemic. DKA is linked to increased morbidity and death, and our metanalysis suggests the necessity for focused public awareness efforts aimed at preventing DKA upon DM1 diagnosis by recognizing and treating symptoms early.
The lockdown has affected the availability of treatment services for patients with chronic diseases such as diabetes. Patients with diabetes have had a short-and long-term influence on glycemic parameters during catastrophes, according to previous studies, due to a lack of medical attention, proper meals, and prescriptions [137][138][139].
In other panels, we found a statistically significant higher perforation rate among acute appendicitis patients during the pandemic. No significant changes in the rate of ruptured ectopic pregnancy were seen before and after the pandemic. Also, rate of orchiectomy rate among testicular torsion was higher during the pandemic compared to before COVID-19. While Littman et al. [41] study did not find any delayed presentation of testicular torsion or its orchidectomy in comparison to pre-COVID-19 years; our study shows an increased pooled rate of orchidectomy testicular torsion during the COVID-19 pandemic emergence in the pooled analysis.
Many factors might justify this finding as well as the fear of COVID-19 infection and delayed referral to medical centers; There is a lot of unknown about Covid-19 disease for people; Therefore, these factors can be considered as an anxiety factor and have a negative effect on people psychologically. The psychological effects of the disease on ordinary people are such that the World Health Organization (WHO) has identified it as a risk factor for the mental health of society and has issued guidelines to prevent its destructive effects on the mental health of society [15,140]. Various studies have shown that the prevalence of this disease and exposure to bad news published on social media about it, has increased anxiety and depressive symptoms, as well as impaired sleep quality [83]. One of the most vulnerable groups to bad news is children, and this bad news can increase their fear and anxiety, and such anxiety can affect their desire to go to the hospital. Since hospitals are at the forefront of the fight against this disease; They are one of the most infected places in terms of the presence of coronavirus and referring to it for the treatment of other diseases can be anxious for healthy people. Multiple pieces of research about pediatric acute appendicitis during the COVID-19 pandemic have clearly shown that staying at home due to public health safety instructions had a negative impact on those who had appendicitis. Several published studies found an increased risk of perforated appendicitis in pediatric patients during the COVID-19 pandemic compared with the pre-COVID-19 period [141]. Elective surgical procedures were discontinued in most centers during the COVID-19 outbreak. Surgical treatments were restricted to the treatment of patients who required immediate surgical or trauma attention. The attempts to reduce needless traffic through the healthcare institution resulted in a considerable decrease in emergency room patient visits. During the COVID-19 pandemic, the medical community noticed a marked increase in prolonged care for various medical emergencies, including pediatric surgical emergencies, which was documented in multiple papers.

Limitations of the study
We only included PubMed as our searching database that some papers might not get included if being published in other indexing databases. While we attributed our study outcomes of interest to patient-related delayed healthcare, delay in performance of pre-hospital Emergency services and in-hospital long waiting times may have affected the study results. Also, delayed or wrong diagnosis and medical negligence might be the reason for delayed referral in some cases that are not discussed in the included papers.

Conclusion
In addition to the dramatic changes that COVID-19 has posed to the trends of chronic diseases treatment and elective medical interventions, the treatment of some very urgent diseases has also been disrupted that is directly associated with unfortunate consequences such as death and disability. In this study, we tried to review the patterns of emergency medical care during the pandemic by focusing on the endpoints that are addressing delayed healthcare seeking. The reorganization of healthcare resources in response to the COVID-19 epidemic has resulted in inadvertent neglect of essential care, particularly in emergency medical circumstances. Following the COVID-19 pandemic, delayed care sought has tended to rise in some medical emergencies, according to our findings. Success in the early diagnosis of medical conditions that were addressed by our study (ACS, aneurismal SAH, acute appendicitis, newly diagnosed T1DM, and testicular torsion) depends to a large extent on people being aware of the early and warning signs of these diseases. It is necessary to comprehensively recall the community about the fundamentals of sickness symptoms, especially for acute diseases. Community education should raise the level of public awareness about the impact of acute medical conditions on health, as well as changes in the distribution of health resources during a pandemic or disaster. This should help them to be able to make decisions about their health even in certain circumstances. One sector involved in this is pre-hospital services and telemedicine that should properly guide people in choosing the best time and best medical center to refer to. Mass media can also influence people's health behaviors and habits and the utilization of health services. Achieving all these ideals requires serious attention to health education in the structure of worldwide health sectors. Also, COVID-19 induced disparities in the allocation of health resources should be amended.